Aspen Meadows Health and Rehabilitation Center
3155 Ave C · Billings, MT · 59102 · 4066568818
90 certified beds For profit - Corporation Chain: Evergreen Healthcare Group
Why this verdict
- 4 citations involved actual harm to residents.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
75% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.52 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.50 | 0.55–0.75 |
| Weekend hours / resident-day | 3.27 | ≈ weekday level |
| Nursing turnover / year | 75% | median 45% |
| Fines (3-yr window) | 1 · $47,658 |
Inspection citations (36 in the current record)
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Actual harm · G March 26, 2026
Ensure that residents are free from significant medication errors.
Corrected April 2, 2026 · Pharmacy Service
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Actual harm · G March 26, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 2, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G March 26, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 2, 2026 · Quality of Life and Care
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Potential for harm · D March 26, 2026
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · D March 26, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · D March 26, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · D March 26, 2026
Ensure each resident receives an accurate assessment.
Corrected April 2, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 26, 2026
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 2, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 26, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected April 2, 2026 · Pharmacy Service
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Potential for harm · D March 26, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected April 2, 2026 · Infection Control
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Potential for harm · D March 26, 2026 · found via complaint
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · D March 26, 2026 · found via complaint
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · D March 26, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 2, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 26, 2026 · found via complaint
Respond appropriately to all alleged violations.
Corrected April 2, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E March 26, 2026 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected April 2, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 26, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 2, 2026 · Quality of Life and Care
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Potential for harm · D September 10, 2025 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected October 9, 2025 · Resident Rights
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Potential for harm · E September 10, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected October 9, 2025 · Nursing and Physician Services
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Potential for harm · D April 10, 2025
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected May 19, 2025 · Resident Rights
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Potential for harm · D April 10, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 10, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 10, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 19, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 10, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 19, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected May 19, 2025 · Pharmacy Service
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Potential for harm · D April 10, 2025
Provide and implement an infection prevention and control program.
Corrected May 19, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 21, 2024 | Fine | $47,658 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 275140 · certified since October 27, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.